The following Q&A was developed by the Global Malaria Programme in collaboration with the Pan American Health Organization (PAHO).
Belize nearly eliminated malaria in the early 1960s. What interventions were used at that time to control malaria, and why was the elimination target not reached?
Beginning in 1950, Belize launched a targeted programme aimed at eliminating malaria nationwide. Key actions included spraying households with insecticides and stepped-up efforts to detect malaria cases through the use of vector control staff, health facilities and community-based health workers. In 1957, a National Malaria Eradication Service (NMES) was established within Belize’s Ministry of Health in response to the global push for eradication. In 1959, the country began systematically collecting malaria case data to monitor programme performance.
These actions yielded results: between 1957 and 1963, annual malaria cases fell from over 1000 to just 17. However, by 1965, the number of cases had increased 12-fold and, subsequently, there were significant fluctuations in cases. Belize has attributed the resurgence in cases to inconsistent implementation of insecticide spraying, a weak surveillance system and a lack of domestic and international funding.
By 1982, over half of all localities in Belize’s 6 districts reported malaria transmission. Cases continued to rise in the 1980s – a trend attributed to a shrinking malaria control budget and an influx of refugees from neighboring malaria-endemic countries during a period of political upheaval.
How did Belize eventually stamp out malaria? What tools or strategies were critical to the success of Belize’s malaria elimination effort?
Over the last 3 decades, Belize has achieved a dramatic reduction in its malaria caseload – from a peak of about 10 000 cases in 1994 to zero indigenous cases in 2019.
The significant decline in cases can be attributed to effective investments – both at domestic and international levels – and to the crucial role of dedicated staff for malaria surveillance. This allowed for early detection of cases, prompt diagnosis and treatment, and complementary preventive measures such as indoor residual spraying and long-lasting insecticidal nets targeted to groups at high risk of malaria, including migrant workers living in border areas with Guatemala and Mexico.
Enhanced surveillance allowed for a more strategic targeting of interventions and available resources in priority areas. The government was able to allocate sufficient resources at central and district levels to ensure the constant availability of supplies for diagnosis and treatment, high coverage of vector control, and a strong healthcare network in communities supported by volunteer collaborators and community health workers. Belize maintained malaria surveillance efforts during the pandemic and made an effort to integrate malaria and COVID-19 surveillance systems.
Which sectors of government – beyond the health sector – contributed to this achievement?
Collaboration with key industries has been crucial to the success of malaria elimination efforts in Belize – notably with the agriculture and tourism sectors. For example, early detection of malaria cases among migrant workers is supported by a collaborative effort between Belize’s national malaria programme and the banana, sugar and citrus industries.
Meanwhile, a long-standing and productive partnership between the national malaria programme and Belize Vector Ecology Center (BVEC) has ensured the implementation and maintenance of entomological surveillance; the findings of such surveillance provide critical information on the distribution and density of malaria-carrying mosquitoes and their resistance to insecticides used in malaria control.
What role did community health workers play in driving down malaria cases?
A dedicated network of trained community-based health workers and voluntary collaborators were the backbone of malaria elimination efforts in Belize. They helped ensure early detection of malaria cases within their respective communities and, for those with a confirmed malaria diagnosis, the provision of effective antimalarial treatment.
What cross-border efforts between Belize and its neighbouring countries – Mexico and Guatemala – are in place to prevent the re-establishment of malaria?
Cross-border collaboration with Mexico and Guatemala began many years ago, as described in Belize’s 2007‒2011 National Health Plan. These collaborative efforts focused on sharing information between teams stationed along borders and at the national level. Community health workers and voluntary collaborators in border areas ensured prompt case detection through rapid diagnostic testing.
In addition, Belize has developed and distributed information, education and communications materials for travellers and migrants through border control and tourist agencies.
Has Belize also participated in regional and global initiatives or programmes to keep malaria at bay?
Belize has participated in a number of regional and subregional initiatives, such as Elimination of Malaria in Mesoamerica and the Island of Hispaniola (EMMIE), financially supported by the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the Regional Malaria Elimination Initiative (RMEI), established by the Inter-American Development Bank with technical leadership from the Pan-American Health Organization (PAHO) and the participation of the Council of Health Ministers of Central America (COMISCA). RMEI supports Central American countries, the Dominican Republic and Colombia in a collaborative effort to eliminate malaria.
With support from USAID, PAHO has provided technical cooperation throughout Belize’s anti-malaria campaign. This success in Belize contributes to PAHO's Disease Elimination Initiative, a collaborative effort between governments, civil society, academia, the private sector and communities to eliminate more than 30 communicable diseases, including malaria, in the Americas by 2030.
At the global level, Belize is also a member of the “E-2025” – a group of countries identified by WHO as having the potential to eliminate malaria by 2025. Through this initiative, Belize and other malaria-eliminating countries have received specialized technical support and have shared innovations and best practices.
How will Belize maintain a robust surveillance and response system to prevent the re-establishment of malaria?
To keep malaria at the forefront of the health agenda in Belize, the country has developed a plan to prevent the re-establishment of malaria transmission. The plan focuses on maintaining malaria surveillance in both the general population and in high-risk groups, as well as improving collaboration within and across sectors.
Training refreshers will be organized for healthcare workers (doctors, nurses, assistant nurses etc.) and vector control personnel to maintain malaria vigilance and good access to diagnosis and treatment. Furthermore, personnel in key sectors, such as agriculture and tourism, will continue to be sensitized on the risk of malaria reintroduction in Belize and the importance of ensuring the timely detection and response to any imported malaria cases.
Are there lessons learned from Belize’s experience that could be applied to other countries in the region?
Belize’s malaria programme has dedicated vector control staff to guide the technical aspects of malaria control interventions and monitor their implementation. The country has maximized access to diagnosis and treatment through health facilities and the use of community health workers and voluntary collaborators in nearly every locality.
Furthermore, the collaboration of Belize’s malaria programme with agricultural farms is unique in the region. Vector control staff have established good relationships with the main farms that hire workers from neighbouring malaria-endemic countries, ensuring the distribution of information, education and communication materials, as well as malaria testing, prompt diagnosis and treatment.
Will Belize draw on lessons from its malaria elimination strategy for other infectious and vector-borne diseases?
The importance of ensuring decentralized access to prompt diagnosis and treatment along with vector control interventions and robust surveillance have been nationally recognized as the main strategies that led to the successful elimination of malaria. These strategies will likely be implemented for other vector-borne diseases such as leishmaniasis and Chagas disease.